Amelia Claire is a CNA and an RHIA who is a clinical documentation trainer for a large health system. The results of a quality improvement study indicated that an informed consent was not obtained for 25% of the surgical procedures performed. Brooke had discussed the problem with the director of the Health Information Department and they have decided to begin corrective action by providing an in-service. The most important participants that should attend this in-service are

Question

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Physicians and residents are the key stakeholders in obtaining informed consent for surgical procedures, as it is their responsibility to explain the procedure and obtain the patient's signed consent. While nurses and unit clerks may assist in this process, they are not ultimately responsible for obtaining the consent. Medical record and quality improvement personnel may be involved in tracking the rates of informed consent and monitoring progress towards improvement, but they may not necessarily have direct involvement in the consent process. Administrators may be responsible for overall policy and procedure, but they are not as directly involved in the informed consent process as physicians and residents.

Amelia Claire Is a CNA and an RHIA Who Is